This guidance updates and replaces NICE guidelines CG10 (published January 2004) and CG119 (published March 2011), and the recommendations on foot care in NICE guideline CG15 (published July 2004).
Diabetes is 1 of the most common chronic diseases in the UK and its prevalence is increasing. In 2013, there were almost 2.9 million people in the UK diagnosed with diabetes. By 2025, it is estimated that more than 5 million people in the UK will have diabetes. In England, the number of people diagnosed with diabetes has increased by approximately 53% between 2006 and 2013, from 1.9 million to 2.9 million. The life expectancy of people with diabetes is shortened by up to 15 years, and 75% die of macrovascular complications.
The risk of foot problems in people with diabetes is increased, largely because of either diabetic neuropathy (nerve damage or degeneration) or peripheral arterial disease (poor blood supply due to diseased large‑ and medium‑sized blood vessels in the legs), or both. Peripheral arterial disease affects 1 in 3 people with diabetes over the age of 50, and can also increase the risk of heart attack and stroke. For more information, see the NICE guideline on lower limb peripheral arterial disease.
Foot complications are common in people with diabetes. It is estimated that 10% of people with diabetes will have a diabetic foot ulcer at some point in their lives. A foot ulcer can be defined as a localised injury to the skin and/or underlying tissue, below the ankle, in a person with diabetes.
Diabetes is the most common cause of non‑traumatic limb amputation, with diabetic foot ulcers preceding more than 80% of amputations in people with diabetes. After a first amputation, people with diabetes are twice as likely to have a subsequent amputation as people without diabetes. Mortality rates after diabetic foot ulceration and amputation are high, with up to 70% of people dying within 5 years of having an amputation and around 50% dying within 5 years of developing a diabetic foot ulcer. This high mortality rate is believed to be associated with cardiovascular disease, and emphasises the importance of good diabetic and cardiovascular risk management. Although people of South Asian, African and African‑Caribbean family origin are more at risk of diabetes, there is no evidence that the prevalence of diabetic foot ulceration and amputation is higher in these subgroups than in the general population of people with diabetes in the UK.
Foot problems in people with diabetes have a significant financial impact on the NHS through primary care, community care, outpatient costs, increased bed occupancy and prolonged stays in hospital. A report published in 2012 by NHS Diabetes estimated that around £650 million (or £1 in every £150 the NHS spends) is spent on foot ulcers or amputations each year.
Despite the publication of strategies on commissioning specialist services for preventing and managing diabetic foot problems, there is variation in practice in preventing and managing diabetic foot problems across different NHS settings, and amputation rates still vary up to fourfold in the UK.
This variation in practice results from a range of factors including the different levels of organisation of care for people with diabetes and diabetic foot problems. This variability depends on geography, individual trusts, individual specialties (such as the organisation and access of the diabetic foot care services) and availability of healthcare professionals with expertise in the management of diabetic foot problems.
The implementation of foot care screening programmes is still varied across the UK, and there is currently a lack of guidance on foot screening strategies aimed at children and young people with diabetes. There is a need for a comprehensive guideline on foot care for people with diabetes that addresses all NHS settings.
Remember that child maltreatment:
can present anywhere
may co‑exist with other health problems, including diabetes.
See the NICE guideline on child maltreatment for clinical features that may be associated with maltreatment.